Lack of sexual interest is the most common sexual complaint in women

The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), which defines psychiatric disorders, defines Hypoactive Sexual Desire Disorder (HSDD) as ‘‘persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity’’ that causes ‘‘marked distress or interpersonal difficulty.’’ Epidemiologic surveys have suggested that from 25 to 50 percent of women report prolonged periods of reduced sexual interest. A lesser but still significant number, on the order of 7 to 15 percent, may meet criteria for HSDD, where loss of sexual interest results in significant distress, and cannot be explained by a co-morbid medical or psychiatric condition, medication side effect, or substance abuse. As a clinician who cares for women I can attest for the common nature of this complaint, and feel frustrated by the lack of therapeutic options.

In June 2010 an FDA advisory board recommended against approval of Filbanserin, the latest drug developed to treat women with decreased libido. Its reason for rejection was the perceived low efficacy of the drug paired with an unacceptably high rate of side effects including dizziness, nausea and fatigue in female users. Data from trials of Filbanserin given to women with HSDD had shown promise, with a reported increased number of “sexually satisfying events” experienced by women who took the drug. The advisory board’s recommendation against approval was disappointing news to women and the physicians who treat them.

Wouldn’t it be great if there were a female Viagra? In fact Pfizer did study the use of Viagra to treat sexual dysfunction in women. However, it was found to be ineffective. The testosterone patch is another option with demonstrated efficacy that has been rejected by the FDA because of safety concerns. These patches are widely available in Europe and have been found to be effective in surgically menopausal women with reduced libido. Unfortunately, their use has been associated with increased risk of breast cancer. Incidentally, testosterone use in men has also been found to have safety concerns and is associated with increased risk of cardiovascular events based on a recent trial published in the New England Journal of Medicine.

Topical estrogen therapy, which treats vaginal dryness and atrophy in post-menopausal women, can be useful for those who experience dysparunia (pain with intercourse). Making things more comfortable certainly can help with sexual desire. However, other than this, doctors are left recommending behavioral solutions and sexual therapy for our female patients to enhance sexual interest, as their eyes glaze over–light a candle, play some music, set aside time for romance and cuddling. Not to make light of relationship and lifestyle contributors, but I wonder what a man would say if I prescribed this for his erectile dysfunction?

Why are options for women so limited? Part of the reason may be because the diagnosis of Hypoactive Sexual Desire Disorder encompasses a multi-factorial array of variables that many are skeptical about addressing with a single drug, unlike male sexuality , I suppose, which is seen as a matter of simple mechanics. Experts in the field note problems with the way that HSDD is defined and revisions to the diagnostic criteria have been proposed for the next version of DSM.

Sexual complaints are common within our culture, however they present differently in men and women. Men complain more about function and women complain more about desire. Disinterest in sex that creates distress in one person may not create distress in another. Is the current paucity of options to treat sexual dysfunction in women related to our cultural notions of appropriate sexuality? Do we really believe that women who complain of decreased libido are hysterical or neurotic? Or, that their complex and ethereal nature can’t be helped by a single drug in the same way that men with a simple mechanical issue can? Or, are we over-medicalizing normal gender differences in sexuality, applying an artificial label “HSDD,” which further pressures women to feel as though they should fantasize and desire sex in the same way as men do. Or, in contrast, have we made a cultural determination that sexuality is not as important to a maturing woman’s well-being as it is to a man’s, and for this reason have we failed to push for solutions that might carry risks that we deem outweigh the less important benefit of promoting sexual desire in women?

I don’t know the answers to these questions, but they are interesting to ponder. The discussion calls to mind the character of 50-something Samantha from Sex in The City. With her healthy libido, is Samantha the woman that women want to be? Or, is she the woman that men want us to be? Or, is she the woman that scares us? Or, is she simply a fantasy?

Juliet K. Mavromatis is an internal medicine physician who blogs at Dr Dialogue.

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I appreciate the last two paragraphs here, Dr. Mavromatis. Good questions.

A 1999 JAMA study, “Sexual Dysfunction in the United States,” concluded “sexual dysfunction is highly associated with negative experiences in sexual relationships and overall well-being.”

The solution to an unsatisfactory sexual partner isn’t a pill. Or perhaps for some in the medical profession today it is. We can accept whatever dissatisfactions life brings us by taking an antidepressant, which is what Gary Greenberg argues we’re doing in “Manufacturing Depression.” More at http://bit.ly/gQWx6z.

Everyone’s always trying to figure out how to make women want more sex. Why must it always be more sex? In a romantic partnership, the higher-libodoed partner tends to be prioritized, and the lower pathologized. I’ve always attributed this to the privileging of male sexual deisre/fantasy. Don’t get me wrong – I’m not advocating the bad old days of demonizing “nymphomania.” However, I think the more-sex-is-always-ideal attitude is pretty closed-minded. There is a middle ground between hyper- and hypo-sexuality. What’s so wrong with it?

Leslye

Totally agree. sometimes I swear that guys get married because they want to have a regular sex partner and when that fades in an older woman (which I think is natural) they get upset and claim that there is something wrong with their wives. I can totally understand why men find younger women so that they can have regular sex. Sometimes I think we are still in the dark ages.

Maribel

If we’re not talking about younger women here – doesn’t diminished sexual desire just come with getting older? When a person is too old to have kids it makes sense that the desire would fade.

Leslye

I totally agree. And I am so glad that the desire finally disappeared. Now when I see a guy I actually get to know them without trying to figure out how to finagle an intimate relationship.

Smells like disease mongering to me, as you say: “over-medicalizing normal gender differences in sexuality”.

When the recently-discredited flibanserin was pulled out of its drug marketing pipeline, Dr. Rosemary Basson of the University of British Columbia in Vancouver observed that this “medical focus on sexual desire” is misplaced, adding: “Desire for sex can also be the desire to feel emotional closeness with someone, to please that person, or to feel attractive. The definition of reduced sexual desire as a ’mental disorder’ assumes that all women have a constant amount of sexual desire that is normal, like the pilot light of a stove. Just turn up the gas, and you’re cooking.”

Follow the money, folks: the market for drugs to rekindle female libido could be even bigger than the $2 billion a year in North American sales alone for erectile dysfunction treatments. More at: “New Desire Drug Claims That Sex Really Is In Her Head” at: http://ethicalnag.org/2009/11/15/boehringer-desire-drug/

anonymous RN

Why should desire fade with age? Yes, sometimes it has to do with relationships & sometimes there’s a physical reason. A number of years ago my at-the-time gyn PA prescribed testosterone cream that was very effective for a short-term problem. I’m sure a female version of Viagra would be a blockbuster drug. Hopefully it’s being worked-on.

Melinda

Anonymous RN, sexual desire fades with age like getting wrinkles when you get older, gray hair when you get older, joints hurt more, ext, etc. I remember a friend of mine telling me that she was terrified if she got the hysterectomy that their desire for sex would diminish. I was thinking, is sex the only thing she has to look forward to? Does she not have anything else going for her? Is being wrinkle free, enhanced boobs, tons of makeup, etc…the self worth of women? Because I think it is more of a disorder to jump into taking a brand new pharmaceutical that you have no idea what adverse reactions you may have to keep her sex life going. Is the relationship that shaky?
If anyone is involved with a significant other who feels that sexiness, looks, sexual desire is that important to a relationship, just wait til you have a debilitating disease. Then you will see the insignificance of sexual desire.

Guest

Just like men, women are people and we’re all different. Not all women are straight, not all women have or want children. There’s a wide spectrum of normal sexual desire and behavior and it doesn’t always fade as we get older.

Re: Viagra-like drugs, I’m concerned about risks, but I have the same thoughts about medication for men. This doesn’t mean it shouldn’t be an option for anyone.

I feel that individualized care is important in this area, as it is for every other health issue. Stereotypes, generalizations, and pressure to conform in either direction are not helpful.

Lisamarie

Is there any argument against this that’s more sophisticated than “I don’t think other people should care about sex so much”? I have a debilitating illness, and the effect on one’s sex life is one of the difficult things about it. Not because it’s what my partner wants- because it’s what I want for myself. Opposition to the idea of this type of drug seems to have an awfully judgemental, lecturing tone, like there’s something wrong with me or my relationship (neither of which you know ANYTHING about) that would make me want this type of intervention.

Guest

Well said. I have a debilitating illness, too, and when I feel up to it, intimate time with my partner makes me feel stronger. There are physical, emotional, and spiritual benefits. It’s not the only important thing in our relationship, and I don’t feel pressure for it. It’s something I want and would prefer not to lose.

In my experience as a psychologist working with couples, low sexual desire in women is primarily because either: their partner is not loving, kind, appreciative, or romantic and they’ve lost their emotional connection OR they are exhausted from working full time, taking care of children, a home, and other responsibilities. In most cases, I don’t see low sexual desire as a medical problem.

Leslye

Your right, it’s not a medical problem but hormonal changes while going through menopause can stop or slowdown the sexual drive. So one could say it’s biological. I mean let me throw this out here, maybe sex is just biological. I’ve been on both sides of the fence. So with my experience of a woman who has been very sexually active (and extremely satisfied), and being post menopausal, I would say 90 percent of the sex drive is biological. 10 percent is our interpretation of what the sexual attraction/drive means. I’m reminded of the book that came out in maybe the 70’s, “The Cinderella Complex”. Us women sure can interpret our sexual relationships to a “grand romance of the century.”

Guest

There’s nothing wrong with what you’re saying about your experience if you don’t try to generalize it to everyone else. What’s so bad about the idea that not all women are the same?

I’m postmenopausal and my experience has been completely different from yours. The medical problem I have that I posted about earlier is not related to menopause. It causes more problems with function than desire, so the closest I get to lack of desire is “too tired” sometimes.

I may not want a pill for it, but I wouldn’t judge someone who did.

Leslye

I come from a place of having worked in the medical/health care fields. I come from a place of a post menopausal woman that has had the desire for sex disappear (which is a good thing). And from those two experiences, I wouldn’t experiment with any new pharmaceuticals, especially ones that would attempt to stimulate my sexual desire. New drugs just haven’t been around long enough to see what happens in the human population.

Guest

All valid points, based on your own experience, and if you had kept it to that before, it would be fine. You should be able to get women’s healthcare targeted to your own needs as a woman.

So should the rest of us. If you don’t want such a drug, don’t use it. Some women would want it, as we’ve seen from comments made by a few people here. Part of being secure and happy with your own life is not judging other people who feel differently.

Leslye

When my desire for sex disappeared, I realized I didn’t miss it any longer. So there wasn’t any melancholy about it. I have to admit I felt freed from this strong biological drive. I felt have only felt relief from this experience. Before this happened I felt sex was something that made couples closer. I see sex in a totally different light now. And I have had great sexual experiences in my past when I had the desire. In the last several years I have talked to several women my age who are experiencing the same feelings about sex since not having the desire. We just aren’t melancholy about it.
However if I was married I would really feel badly for my husband if he still had a desire. I just don’t think I would risk taking a new pharmaceutical in order to get back the desire.

“Part of being secure and happy with your own life is not judging other people who feel differently.” ( Guest, comment #17 – ) With all due respect, I’m not so much concerned about what other PEOPLE choose to do in the privacy of their own bedrooms, but I am extremely concerned about Big Pharma and their proven role in marketing-based medicine. They stand to gain the most from “medicalizing” virtually everything in our lives.

Dr. Ben Goldacre, author of ‘Bad Science”, laments this “disease mongering” (which is what drug companies have had to do because all the good diseases are already taken). He writes about this “medicalization of everyday life”: “Recent favourites include social anxiety disorder (a new use for SSRI antidepressant drugs), female sexual dysfunction, osteopenia, the widening diagnostic boundaries of restless leg syndrome, and even night eating syndrome.”

It’s important to keep in mind that Dr. Goldacre and others like Jan Henderson, Barbara Fontana and others commenting here are NOT saying these are not real FOR SOME PEOPLE. But if Big Pharma can convince us that we all likely suffer from these maladies, there is Big Money to be made.

Guest

Good point, and I don’t see anyone here who’s thrilled with the definition or marketing of HSDD. What I’m trying to address is the cultural issues mentioned in this post, which go beyond “do women need these drugs or not?” I just don’t think that making generalizations about women, sex, or relationships is a great way to fight the influence of Big Pharma.

One way to fight Big Pharma is to publicize what they say and do behind closed doors, as Ray Moynihan does for this very issue in “Sex, Lies and Pharmaceuticals: How Drug Companies Plan to Profit from Female Sexual Dysfunction.”

Leslye

if you do not buy the drug, you do not support the Big Pharma. Drugs that have been around for years and years are much safer. I must be one lucky soul with my experience. In my circle of friends this is not a sensitive topic, so whatever I have done to anger folks I am truly sorry, but I have to also admit after looking at all my postings, I am lost on the accusation that I have judged someone for wanting to take this new drug ( that has not become available yet) in this article.

Guest

I don’t think anyone is angry with you – certainly not me, and I’m sorry if I came across as too harsh. I just felt that you were trying to generalize your experience too much, re: female sexuality (or lack of it) after a certain age or hormone status is reached.

There was a bit of a trend earlier in the comments that went in this direction. A few people, including me, jumped in to mention their experience, which has been different. Your feelings and those of your friends, are just as valid. What I should’ve mentioned is that I know of many women whose doctors assumed that they wouldn’t/shouldn’t care about sex after a certain age. That can cause harm, too, just as pressure to take a drug for desire could harm someone who is happy without it.

Dr. Mavromatis, surprisingly, did not quote Moynihan’s extensive work on this subject, but did of course mention that HSDD is now included in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) – which in itself is hardly a ringing endorsement that HSDD is indeed a valid disorder.

The fact that psychiatric diseases can be invented (or, as with homosexuality, UN-invented) and the DSM criteria tweaked in response to social conditions and Big Pharma influence is inherently problematic. Homosexuality, for example, was listed as a psychiatric disorder in every edition of the DSM – until the American Psychiatric Association had the misfortune to hold their 1970 annual conference in San Francisco at the height of the gay rights movement. Activists stormed the conference and the upshot was that the APA removed homosexuality from the very next edition of the DMS, determining that it was not and never had been a psychiatric disorder.

And pervasive Big Pharma influence on those charged with writing each DSM edition are well documented. A 2006 Tufts University study, for example, found that over half of 170 psychiatric “experts” who helped write this latest edition had financial links to pharmaceutical companies.

Interest in sex varies. Low interest is NOT a disease and putting it in that box medicalizes behavior. Yes,lets provide help guidance or support for women(or men) who want to “improve” their sex drive but do not call it an illness and do not look for a pharmaceutical solution.

Thanks for the great discussion. Here’s a link to Ray Moynihan’s book: “Sex, Lies and Pharmaceuticals” http://raymoynihan.com/books/. As Carolyn Thomas points out his point of view is that HSDD is a disease manufactured by pharma to promote sales of their next blockbuster drug. I’m not sure that I believe the HSDD is truly a disorder, However, I do believe that there are both biological and psychological aspects to low libido in women. I am wondering if the FDA’s rejection of two drugs that have some demonstrated efficacy in treating this is an example cultural sexism–sex is less important for female quality of life than male quality of life–thus not worth the risks/side effects.